Analysis of Treatment Guidelines for Obsessive Compulsive Disorder
The topic I selected for my analysis of treatment guidelines is Obsessive Compulsive Disorder (OCD). The reason I selected this disorder is because OCD is common. OCD affects more than 2% of the population. This is more than one in 50 people. “More people suffer from OCD than from panic disorder or bipolar depression” (Stoppler & Hecht, 2012). “Some researchers have estimated the disorder is found in as many as 10 % of outpatients in psychiatric clinics. These figures make OCD the fourth most common psychiatric diagnosis. Epidemiological studies in Europe, Asia, and Africa have confirmed these rates across cultural boundaries” (Sadock & Sadock, 2007).
OCD is considered a chronic anxiety problem. People with OCD have excessive doubts, or worries. While all people experience excessive doubts or worries occasionally, people with OCD can let these thoughts control their lives. They may cope with common problems by indulging in compulsions that are excessive or do not make logical sense in order to neutralize the feelings of increased anxiety and stress associated with these thoughts and or worries.
OCD is a disease characterized by recurrent intrusive thoughts called obsessions. Obsessions themselves are the unwanted thoughts or impulses that recur repeatedly in the mind. These intruding thoughts can be fears, unreasonable worries, or a need to do things. When a person is tense or under stress, the obsessions can worsen. Having these obsessions can result in compulsions or repetitive behaviors. Compulsions are the behaviors that may result from the obsessive thoughts. The most common compulsions include repetitive washing (hands or objects) and “checking” behaviors. Compulsions may be rituals, repeating certain actions, counting, or other recurrent behaviors. Some people with OCD are obsessed with germs or dirt (Stoppler & Hecht, 2012).
Those affected by OCD may have mild or severe symptoms. People with mild OCD can sometimes control their compulsive behaviors for a set amount of time such as while they are at work. Thus they are able to hide their condition. In severe cases of OCD, the disease can be so prominent that it interferes with occupational and social functioning of an individual and can be disabling. OCD symptoms often appear early in life. Most commonly OCD symptoms present in childhood, teenage years or early adulthood. Both genders and all races are equally affected. This disease typically persists throughout a person’s life with fluctuations in severity throughout life (Stoppler & Hecht, 2012).
Medical researchers have demonstrated that OCD is a brain disorder caused by incorrect information processing. Those with OCD claim their brains become stuck on a particular thought or certain urge. OCD was considered untreatable in the past. However today, advances in medical management and therapy have greatly increased the odds that someone with OCD can be successfully treated. While there is no known specific cause for OCD, family history and chemical imbalances in the brain are thought to contribute to the development of the illness. Generally, while people who have relatives with OCD are at a higher risk of developing the disorder, most people with the illness have no such family history. A specific chromosome/gene variation has been found to possibly double the likelihood of a person developing OCD. It is thought that an imbalance of the chemical serotonin in the brain may also contribute to the development of OCD (Dryden-Edwards & Stoppler, 2012). Also, “over the last ten years, there has been a mounting body of evidence that suggests there is a small subgroup of individuals whose childhood onset of OCD may have been triggered by streptococcal throat infections” (Reitman, M., 2011).
OCD can be accompanied by other anxiety disorders. Some of the additional anxiety disorders seen in people suffering from OCD include eating disorders, depression and other psychological conditions. Some people affected with OCD have the insight in understanding that their thoughts and actions are not realistic whereas other people lack this insight.
“Antidepressants that affect the neurotransmitter serotonin can provide relief for up to 75% of people with OCD. The most commonly prescribed drugs are the selective serotonin reuptake inhibitors (SSRIs) such as Paroxetine, Sertraline and Fluoxetine.” Behavioral therapy can also be an effective treatment option. Psychotherapy for OCD may involve insight into disruptive thoughts and impulses. Psychotherapy may also provide a means of confronting the disruptive thoughts and impulses in an attempt to control the associated compulsions (Stoppler & Hecht, 2012).
What I have seen in clinical practice sites (satellite clinics for follow up care and medical management through John Peter Smith Hospital) are young adults presenting with varying degrees of severity of OCD. The patients seen in clinical practice thus far have been young adults between the ages of 20-30 years. I have seen both male and female patients with OCD. The treatment of choice with these patients has been the use of SSRIs and psychotherapy. The patients have shown definite improvement. All but one patient functions without any debilitating effects. The PMHNP is currently adjusting the medication of this individual.
Multiple clinical treatment guidelines for OCD were evaluated and reviewed for this analysis. The reviewed guidelines include the American Psychiatric Association (APA) – guidelines for treating OCD (2007), the National Institute of Health and Clinical Excellence (NICE) – practice guidelines for the treatment of patients with OCD and which is responsible for providing national guidance on treatments and care for people using the National Health Service (NHS) in England and Wales. NICE is recognized as being a world leader in setting standards for high quality healthcare and is the most prolific producer of clinical guidelines in the world (2005). Other clinical guidelines reviewed include the Clinical Practice Guidelines for the Management of OCD from Indian Psychiatry (2005), The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of OCD (2008), and the National Guideline Clearinghouse for the practice parameters for the assessment and treatment of children and adolescents with OCD (2012).These guidelines were obtained after an exhaustive search looking at multiple sources available both inside and outside of the United States.
The APA guidelines (2007) level of evidence used to support the treatment guidelines included “guideline development under the auspices of the Steering Committee on Practice Guidelines. The key features of this process with regards to this document included a comprehensive literature review to identify all randomized clinical trials as well as less rigorously designed clinical trials and case series when evidence from randomized trials was unavailable. The development of evidence tables were used which summarized key features of each identified study, including funding source, study design, sample sizes, subject characteristics, treatment characteristics and treatment outcomes.” The production of multiple revised drafts (with widespread review consisting of 11 organizations and 68 individuals) were also included. Approval by the APA Assembly and Board of Trustees with planned revisions at regular intervals was included as well.” Also, in 2012 the original authors of the 2007 guidelines reviewed results of the current literature in relation to the recommendations of the 2007 guidelines and reaffirmation was given. The method of guideline validation consisted of both external and internal peer review. “The method of guideline validation included iterative guideline drafts reviewed by a steering committee, other experts, allied organizations, APA members, and the APA Assembly Board of Trustees and substantial revisions were addressed or integrated from the comments of these multiple reviewers” (Agency for Healthcare Research and Quality, 2012).
The APA guidelines (2007) treatment recommendations included psychiatric management which encompassed establishing a therapeutic alliance, assessing the patient’s symptoms, using rating scales to rate baseline severity of OCD symptoms and other co-occurring conditions. It also included assessing the patient’s potential for self-injury or suicide, completing a detailed psychiatric history looking for co-morbid conditions, looking at the course of symptoms and treatment history, and establishing goals for treatment. In addition, treatment recommendations included establishing the appropriate setting for treatment (inpatient or outpatient), enhancing treatment adherence which included issues such as access to support groups, education regarding medication side effects, consideration of treatment costs, insurance coverage and transportation issues related to treatment. Also, the choice of an initial treatment modality (pharmacotherapy and/or psychotherapy), selection of a specific pharmacological treatment, selection of a specific form of psychotherapy, implementation of a treatment plan including pharmacotherapy and psychotherapy/cognitive behavioral therapy, changing treatments and pursuing sequential treatment trials, and discontinuing active treatment were included in the treatment recommendations (Agency for Healthcare Research and Quality, 2012).
First line treatment recommendations from the APA guidelines include the use of cognitive behavioral therapy (CBT) with exposure response prevention (ERP), or treatment with SSRI or the use of SSRI with CBT and ERP. The second line recommendations for a moderate response to treatment includes the addition of a second generation antipsychotic for augmentation and CBT with ERP if not already provided or the addition of CBT to ERP if not already provided. For little or no response, one may try changing to a different SSRI or Clomipramine. In addition, augmentation with a second generation antipsychotic or changing to Venlafaxine or Mirtazipine may be tried. After that, for moderate to little response, recommendations include either changing to a different second generation antipsychotic agent or changing to a different SSRI. Augmentation with Clomipramine, Buspirone, Pindolol, Morphine Sulfate, Inositol, a glutamate antagonist or Topiramate can also be tried. For little to no response, changing to Dextroamphetamine (monotherapy), Tramadol (monotherapy), Ondansetron (monotherapy), or an MAO can be tried. As a last resort, another option to consider includes the use of deep brain stimulation, ablative neurosurgery or transcranial magnetic stimulation (Lambert, 2008).
The APA guidelines (2007) utilized the following types of research studies to support the use of the guidelines. “The evidence base for practice guidelines was derived from two sources: research studies and clinical consensus. Where gaps existed in the research data, evidence was derived from clinical consensus and obtained through extensive review of multiple drafts of each guideline.” In addition, the nature of the supporting evidence included double-blind randomized clinical trials, randomized clinical trials, clinical trials, cohort or longitudinal studies, case-control studies, review with secondary data analysis (structured analytic review of existing data/meta-analysis or a decision analysis), reviews (qualitative reviews and discussion of previously published literature without a quantitative synthesis of the data), plus textbooks, expert opinion and case reports” (Agency for Healthcare Research and Quality, 2012). There was no mention of how subjects were selected for trials and studies in guideline development.
The APA (2007) guidelines are very relevant and can be easily utilized and adapted to the clinical areas in which I have been precepted. However, I did not find any specific information within the guidelines as it pertains to children and if included could improve application to clinical practice.
The National Institute for Health and Clinical Excellence (NICE) guidelines were developed in 2005 and used for guidance and treatment for people with OCD in the United Kingdom (UK) with application of their guidelines around the world. These guidelines recommended management of OCD in both adults and children. The level of evidence used to support these guidelines included NICE’s work in commissioning the development of guidance from the National Collaborating Centre for Mental Health. The Centre established a guideline development group (GDG), which reviewed the evidence and developed the recommendations. All evidence was classified according to an accepted hierarchy of evidence that was originally adapted from the US Agency for Healthcare Policy and Research Classification. Recommendations were then graded A to C based on the level of associated evidence. This grading scheme is based on a scheme formulated by the Clinical Outcomes Group of the NHS Executive in 1996” (National Institute for Health and Clinical Excellence, 2005).
The guidelines were developed utilizing GDG meetings, special advisors, and national and international experts to ensure up to date evidence was included in the guidelines. Clinical questions were used to guide the identification and interrogation of the evidence-base relevant to the topic of the guideline utilizing the PICO (patient, intervention, comparison and outcome) framework. A stepwise, hierarchical approach was taken to locate and present evidence to the GDG. Recommendations from a range of sources were used to include Centre for Clinical Policy and Practice of the New South Wales Health Department (Australia), Clinical Evidence Online Cochrane, Collaboration New Zealand Guideline Group, NHS Centre for Reviews and Dissemination, Oxford Centre for Evidence-Based Medicine, Oxford Systematic Review, Development Programme Scottish Intercollegiate Guidelines Network (SIGN), and the United States Agency for Health Research and Quality (National Institute for Health and Clinical Excellence, 2005).
Recommended treatment from the NICE guidelines incorporated some of the same treatment modalities as the American Psychological Association guidelines. NICE guidelines endorsed a multidisciplinary approach and first line pharmacological treatment included the use of SSRIs (although unlike the APA guidelines, no specific drugs mentioned). CBT was also highly recommended as well as the use of ERP therapy (National Institute for Health and Clinical Excellence, 2005).
Research studies supporting the use of NICE guidelines were formulated from well-conducted randomized clinical trials (RCTs). The initial search for RCTs involved searching the standard mental
health bibliographic databases (Embase, Medline, PsycInfo, Cochrane Library) for all RCTs potentially relevant to the guidelines. After the initial search results were scanned liberally to exclude irrelevant papers, the review team then used a purpose built study information database to manage both the included and the excluded studies (eligibility criteria were developed after consultation with the GDG). Recent high-quality English-language systematic reviews were used primarily as a source of RCTs. Meta-analysis was then used, where appropriate, to synthesize the evidence (National Institute for Health and Clinical Excellence, 2005).
There was no specific mention of study sample size, the subjects or how they were selected for the RCTs used in the guideline development. Although I do not have specific details regarding the studies conducted, the data gleaned is representative of the patient population seen in the clinical areas where I have been precepted. Also, the guidelines developed were relevant and could be used in the clinical setting. The NICE guidelines did not exclude any patient population, treatment or therapy. Some areas in which the guidelines could improve would be including data about long term efficacy of SSRI use in OCD, relapse prevention in OCD and the optimal dose of a SSRI for OCD. Again, notation of specific SSRI medication recommendations would have been useful too.
The Clinical Practice Guidelines for the Management of OCD from Indian Psychiatry (2005) has no mention of the level of evidence to support their OCD treatment guidelines although there is a flow chart/algorithm depicted within the guidelines. The flow chart begins with the patient presenting with OCD symptoms. At this point, there is either a confirmation of OCD or exclusion of OCD related to other psychiatric disorders or other organic causes. If OCD is confirmed, the recommended treatment is then use of a SSRI plus exposure response prevention (ERP) therapy for a 10-12 week trial. If no change in the patient’s condition, Clomipramine or an atypical antipsychotic will be added. Still if no change in the patient’s condition, a trial of another antidepressant such as Venlafaxine or a MAOI is recommended. If no change in the patient’s condition, Buspirone or Clonazepam will be added. If the patient still does not respond and has extremely severe and non-remitting OCD, IV Clomipramine or psychosurgery (cingulotomy or internal capsulotomy) is recommended (Gautam, et., al., 2005).
There were no research studies noted to support the use of the guidelines published in Indian Psychiatry. Likewise, there was no mention of clinical trials conducted to support the use of these guidelines. The guidelines (treatment for OCD) are applicable to the patient population seen in the clinical practice settings in which I have been precepted. The guidelines did not discriminate between gender or age. No cultural issues were addressed. There were no exclusions of particular therapies or medications that, if included would have improved the clinical guideline application into practice. However, I did find it disturbing that there was no mention of the level of evidence to support the OCD treatment guidelines nor clinical trials or research studies conducted to support the use of these guidelines.
The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of OCD (2008) level of evidence to support the use of these guidelines is based on evidence from controlled clinical studies and trials adhering to the principles of evidence-based medicine. “Data were extracted from published articles from the Medline database and the Scientific Citation Index at Web of Science” (Bandelow, et., al., 2008). Recommendations were based on studies that fulfilled specific methodological requirements. Also, open studies and case reports were collected and reviewed. Meta-analysis was also used. The levels of evidence were rated and the treatment guideline recommendations contained levels of evidence that were either full evidence from controlled studies or limited positive evidence from controlled studies which provided for a good risk benefit ratio.
The first line treatment for OCD recommended by WFSBP (2008) includes the use of SSRIs. Specifically the medications – Escitalopram, Fluvoxamine, Fluoxetine, Paroxetine and Sertraline. The recommendations also stated that the TCA Clomipramine was equally effective but less well tolerated than the SSRIs. Second line, Mirtazapine was also an effective option. The therapies recommended were CBT/ERP. The recommendations noted that electroconvulsive therapy (ECT) may be effective but should be restricted to carefully selected patients. The recommendations also noted mostly negative results from transcranial magnetic stimulation. Also, neurosurgery and deep brain stimulation were only tried in a few patients in uncontrolled studies and the results were mixed.
The WFSBP (2008) guidelines were developed utilizing a consensus panel of 30 international experts and the guideline recommendations were based on 150 published randomized, placebo or comparator-controlled clinical studies (RCTs) and a 130 open studies and case reports (Bandelow, et., al., 2008). These research studies support the use of these guidelines.
Although there was no mention of sample size, subjects or how they were selected, the guidelines are representative of the patient population seen in the clinical practices where I have been precepted. These guidelines have relevancy and utility in clinical practice. No cultural issues were addressed. The guidelines did not exclude either gender and included all age groups. There were no medications or therapies that were excluded that, if included, would have improved clinical practice.
The National Guideline Clearinghouse for the practice parameters for the assessment and treatment of children and adolescents with OCD (2012) based recommendations on the critical appraisal of empirical evidence (when available) and clinical consensus (when not). The level of evidence used to support the use of these treatment guidelines was derived from “information and recommendations obtained from literature searches using the Medline, PubMed, PsycINFO, and Cochrane Library databases and by an iterative bibliographic exploration of articles and reviews. Using similar strategies and databases, obsessive-compulsive disorder AND randomized controlled trial were searched to yield 353 citations, including 11 reviews. Key quality domains were examined including descriptions of the study population, randomization, blinding, interventions, outcomes, sources of sponsorship or funding, and statistical analysis. For these guideline recommendations, 65 publications were selected for careful examination based on their weight in the hierarchy of evidence attending to the quality of individual studies, relevance to clinical practice, and the strength of the entire body of evidence” (National Guideline Clearinghouse for the practice parameters for the assessment and treatment of children and adolescents with OCD, 2012).
Treatment recommendations include “the psychiatric assessment of children and adolescents being routinely screened for the presence of obsessions and/or compulsions or repetitive behaviors. If the screening suggests OCD symptoms might be present, clinicians then fully evaluate the child using the DSM-IV-Text Revision (DSM-IV-TR) criteria and scalar assessment. A complete psychiatric evaluation should then be performed, including information from all available sources and comprising standard elements of history and a mental state examination, with attention to the presence of commonly occurring co-morbid psychiatric disorders. In addition, a full medical, developmental, family, and school history should be included with the psychiatric history and examination. Also, when possible, CBT is the first line treatment for mild to moderate cases of OCD in children. For moderate to severe OCD, medication is indicated in addition to CBT. Selective Serotonin reuptake inhibitors (SSRIs) are the first-line medications recommended for OCD in children and should be used according to American Academy of Child and Adolescent Psychiatry (AACAP) guidelines to monitor response, tolerability, and safety. The modality of assigned treatment should be guided by empirical evidence on the moderators and predictors of treatment response. Multimodal treatment is recommended if CBT fails to achieve a clinical response after several months or in more severe cases. Medication augmentation strategies are reserved for treatment-resistant cases in which impairments are deemed moderate in at least one important domain of function despite adequate mono-therapy. Lastly, empirically validated medication and psychosocial treatments for co-morbid disorders should be considered” (National Guideline Clearinghouse for the practice parameters for the assessment and treatment of children and adolescents with OCD, 2012).
The National Guideline Clearinghouse for the practice parameters for the assessment and treatment of children and adolescents with OCD (2012) utilized the following types of research studies to support the use of the guidelines. A meta-analysis looked at randomized controlled trials, controlled trials, as well as case series and reports. There was no specific mention of sample size, subjects or how the subjects were selected. However, the quality of the studies were rated and weighted according to a rating scheme (National Guideline Clearinghouse for the practice parameters for the assessment and treatment of children and adolescents with OCD, 2012). These guidelines are certainly relevant and have utility in clinical practice. They could be easily utilized in the clinical setting. These particular guidelines speak to children and adolescents only. Although adults were excluded, many of the treatment recommendations were very similar to those of the American Psychiatric Association.
From the treatment guidelines reviewed, the one I would select to use in clinical practice would be the American Psychiatric Association (APA) 2007 guidelines. These guidelines were reaffirmed in 2012 so the information is current. The algorithm (see page 10) is easy to follow when selecting a treatment modality for the patient. The guidelines give the provider a choice as to whether to initially use pharmacologic agents or psychotherapy or both based on the nature and severity of the patient’s symptoms, current medications, treatment history, and the availability of CBT. The guidelines have the level of evidence to support their use and relevance in clinical practice. There are also numerous research studies of differing types supporting the richness of the data used to formulate these treatment guidelines. I really like the emphasis that is also placed on establishing a therapeutic alliance and treatment goals with the patient. The guidelines also emphasize the necessity of a very thorough psychiatric assessment to include documentation of concomitant conditions such as depression, substance abuse, attention hyperactivity disorder and other psychiatric conditions. I think this is very important as many patients with OCD also have other co-morbid psychiatric illnesses. The only modification I would make is to incorporate guideline specific data related to children and adolescents. This information could be obtained from the National Guideline Clearinghouse for the practice parameters for the assessment and treatment of children and adolescents.
I chose C.V. (a practicing PMHNP) to evaluate the guidelines I selected. He stated he felt the APA (2007) guidelines (reaffirmed in 2012) were practical and evidence based. He felt they were relevant and had good utility in clinical practice. He states the protocols his clinic utilizes are very similar and probably have been adopted from the existing APA treatment guidelines. He said he felt the guidelines were comprehensive but still flexible enough that one could practice without feeling “boxed into a corner.” He emphasized the importance of psychotherapy and liked the fact that this was addressed in the APA guidelines. In a nutshell, he stated he felt like the APA guidelines were essentially the standard of care when treating patients with anxiety disorders such as OCD (Vickers, 2013).
APA Algorithm for Treatment of Obsessive-Compulsive Disorder
Lambert, M., 2008
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